Recommendations
2065
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 17-01746-116 | Comprehensive Healthcare Inspection Program Review of the Jonathan M. Wainwright Memorial VA Medical Center, Walla Walla, Washington | Comprehensive Healthcare Inspection Program | ||
1 The Facility Director ensures that a senior-level committee is established and responsible for key Quality, Safety, and Value functions.
Closure Date:
2 The Facility Director ensures the Patient Safety Manager completes the required minimum of eight root cause analyses each fiscal year and monitors the manager’s compliance.
Closure Date:
3 The Chief of Staff ensures that anticoagulation management program quality assurance data are analyzed and reported to the Pharmacy and Therapeutics Committee and monitors program managers’ compliance.
Closure Date:
4 The Chief of Staff ensures clinicians consistently provide specific education to patients with newly prescribed anticoagulant medications and monitors clinicians' compliance.
Closure Date:
5 The Chief of Staff ensures clinicians consistently obtain and document all required laboratory tests prior to initiating anticoagulant medications and monitors clinicians' compliance.
Closure Date:
6 The Chief of Staff ensures all required elements specific to anticoagulation management are included in competency assessments for employees actively involved in the anticoagulant program and monitors compliance.
Closure Date:
7 The Associate Director ensures environment of care inspections are conducted at the required frequency and monitors compliance.
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8 The Associate Director ensures core team members consistently participate in environment of care rounds and monitors compliance.
Closure Date:
9 The Chief of Staff and the Nurse Executive ensure that the Community Nursing Home Oversight Committee includes representation by all required disciplines and monitor compliance
Closure Date:
10 The Nurse Executive ensures social workers conduct cyclical clinical visits with the frequency required by Veterans Health Administration policy and monitors social workers’ compliance.
Closure Date:
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| 17-01758-104 | Comprehensive Healthcare Inspection Program Review of the Hampton VA Medical Center, Hampton, Virginia | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures that clinical managers communicate to the Peer Review Committee all completions of individual improvement actions and monitors managers’ compliance.
Closure Date:
2 The Chief of Staff ensures clinical managers consistently review Ongoing Professional Practice Evaluation data with the frequency required by facility policy and monitors the managers’ compliance.
Closure Date:
3 The Chief of Staff requires clinicians to ensure patients with newly prescribed warfarin have international normalized ratio measurements taken within 7 days of warfarin initiation, and monitor compliance.
Closure Date:
4 The Chief of Staff requires clinical managers to complete competency assessments annually for employees actively involved in the anticoagulant program and monitors managers’ compliance.
Closure Date:
5 The Chief of Staff ensures clinicians consistently include identification of the receiving provider in transfer documentation and monitors the clinicians’ compliance.
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6 The Associate Director ensures all areas of the facility are inspected at the required frequency and monitors compliance.
Closure Date:
7 The Associate Director ensures core team members consistently attend environment of care rounds and monitors compliance.
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8 The Associate Director ensures the Chesapeake community based outpatient clinic panic alarms are tested monthly and monitors compliance.
Closure Date:
9 The Associate Director ensures storage carts and shelves at the Chesapeake Community Based Outpatient Clinic have solid bottom shelves and monitors compliance.
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10 The Associate Director ensures locked mental health unit panic alarm testing includes documentation of VA Police response time and monitors compliance.
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11 The Associate Director ensures that adequate security surveillance is provided through functional and regularly tested equipment and monitors compliance.
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12 The Associate Director ensures locked mental health unit employees and Interdisciplinary Safety Inspection Team members receive annual training for identification and correction of environmental hazards and proper use of the Mental Health Environment of Care Checklist and monitors compliance.
Closure Date:
13 The Chief of Staff ensures providers include a history of previous adverse experience with sedation and anesthesia in the history and physical and/or pre-sedation assessment and monitors providers’ compliance.
Closure Date:
14 The Chief of Staff ensures that physicians who perform or assist with moderate sedation procedures receive training for the provision of moderate sedation care prior to being re-privileged and that training is documented and monitors compliance with training and documentation.
Closure Date:
15 The Facility Director ensures that the Community Nursing Home Oversight Committee meets at least quarterly, includes representatives from all required disciplines, and integrates processes into the facility’s quality improvement program with documentation of these processes in the facility’s executive-level committee meeting minutes and monitors compliance.
Closure Date:
16 The Chief of Staff ensures the Community Nursing Home Review Team completes annual reviews within the required timeframe and submits exclusionary criteria exemption requests when a community nursing home meets the threshold of four or more deficiencies and monitors the team’s compliance.
Closure Date:
17 The Chief of Staff ensures social workers and registered nurses conduct and document cyclical clinical visits with the frequency required by Veterans Health Administration policy for community nursing home oversight and monitors social workers’ and registered nurses’ compliance.
Closure Date:
18 The Associate Director ensures that Domiciliary Care for Homeless Veterans Program, general domiciliary, and Substance Abuse and Post-Traumatic Stress Disorder Residential Rehabilitation Treatment Program employees conduct and document daily resident room inspections for unsecured medications and monitors employees’ compliance.
Closure Date:
19 The Associate Director ensures that adequate security surveillance is provided through functional and regularly tested equipment and monitors compliance.
Closure Date:
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| 15-01580-108 | Healthcare Inspection - Review of Montana Board of Psychologists Complaint and Assessment of VA Protocols for Traumatic Brain Injury Compensation and Pension Examinations | National Healthcare Review | ||
1 We recommended that the Executive in Charge, Office of the Under Secretary for Health and Acting Under Secretary for Benefits convene experts to develop a plan to ensure that personnel performing the traumatic brain injury Compensation and Pension examination have comprehensive training on the evaluation of traumatic brain injury, including the assessment and evaluation of cognitive disorders.
Closure Date:
2 We recommended that the Executive in Charge, Office of the Under Secretary for Health and Acting Under Secretary for Benefits convene experts to develop a plan to develop requirements for documentation of the traumatic brain injury Compensation and Pension examination process, including the basis for determinations of cognitive impairment and other residuals of traumatic brain injury.
Closure Date:
3 We recommended that the Executive in Charge, Office of the Under Secretary for Health and Acting Under Secretary for Benefits convene experts to develop a plan to consider whether to provide disability ratings to veterans with claims arising from cognitive issues based upon their clinical signs and symptoms, not primarily based upon the diagnosis or cause of their cognitive deficits (that is. traumatic brain injury or post-traumatic stress disorder).
Closure Date:
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| 17-02678-107 | Healthcare Inspection—Alleged Failure in Patient Notification of Test Results, VA Connecticut Healthcare System, West Haven, Connecticut | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director ensure providers follow the Veterans Health Administration policy related to patient notification of test results.
Closure Date:
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| 17-01750-97 | Comprehensive Healthcare Inspection Program Review of the VA Northern California Health Care System, Mather, California | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures peer reviewers consistently use at least one of the important aspects of care to evaluate peer review findings and monitors reviewers’ compliance.
Closure Date:
2 The Chief of Staff ensures service chiefs consistently review Ongoing Professional Practice Evaluation data every 6 months and monitors the service chiefs’ compliance.
Closure Date:
3 The Chief of Staff ensures pharmacy managers implement an anticoagulation management standard operating procedure that contains all elements required by the Veterans Health Administration.
Closure Date:
4 The Chief of Staff ensures clinicians consistently obtain all required laboratory tests prior to initiating anticoagulant medications and monitors clinicians’ compliance.
Closure Date:
5 The Chief of Staff ensures clinical managers include all required elements in competency assessments for employees actively involved in the anticoagulant program and monitors managers’ compliance.
Closure Date:
6 The Chief of Staff ensures clinicians consistently include patient or surrogate informed consent in transfer documentation and monitors clinicians’ compliance.
Closure Date:
7 The Associate Directors ensure required team members participate on environment of care rounds and monitor compliance.
Closure Date:
8 The Associate Director ensures VA Police conduct required testing of the locked mental health unit security surveillance television system and monitors VA Police compliance.
Closure Date:
9 The Associate Director ensures all locked mental health unit employees and Interdisciplinary Safety Inspection Team members complete the required training on identification and correction of environmental hazards, including the proper use of the Mental Health Environment of Care Checklist, and monitors compliance.
Closure Date:
10 The Chief of Staff ensures providers include the history of previous experience with sedation and anesthesia in the history and physical exams and/or pre-sedation assessments and monitors compliance.
Closure Date:
11 The Chief of Staff ensures clinical teams use a checklist that includes all required elements to conduct and document timeouts prior to moderate sedation procedures and monitors the teams’ compliance.
Closure Date:
12 The Chief of Staff ensures the Community Nursing Home Review Team completes required annual reviews and monitors the team’s compliance.
Closure Date:
13 The Chief of Staff ensures social workers and registered nurses conduct cyclical clinical visits with the frequency required and monitors social workers’ and registered nurses’ compliance.
Closure Date:
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| 17-05909-106 | Administrative Investigation – VA Secretary and Delegation Travel to Europe | Administrative Investigation | ||
1 Secretary Shulkin reimburses the $4,312 paid by VA to cover Dr. Bari’s travel costs.
Closure Date:
2 Secretary Shulkin consults with the Office of General Counsel to determine the value of the Wimbledon tickets; grounds pass; and any food, parking, and other tangible benefits Ms. Gosling provided in connection with Wimbledon and reimburse that amount to her. If Ms. Gosling declines to accept reimbursement, Secretary Shulkin reimburses such amount to the US Treasury.
Closure Date:
3 The Deputy Secretary of Veterans Affairs confers with the Offices of General Counsel, Human Resources, and Accountability and Whistleblower Protection to determine the appropriate administrative action to take, if any, against Ms. Wright Simpson and any other individuals associated with the Europe trip.
Closure Date:
4 The Deputy Secretary of Veterans Affairs ensures that a thorough audit is conducted of the expense vouchers, travel authorizations, and the time and attendance records for all travelers on the Europe trip. Any overpayments should be reimbursed to VA by the traveler and any required leave adjustments should be made. Detailed results of the audits, including supporting documentation, shall be provided to the Office of Inspector General no later than thirty days following the publication of this report.
Closure Date:
5 The Deputy Secretary of Veterans Affairs ensures that the Office of General Counsel (i) reviews and enhances the training provided to staff on travel planning, approvals, and the solicitation or acceptance of gifts; and (ii) provides refresher training on these topics to all travelers on the Europe trip as well as all staff involved in the planning and implementation of the trip.
Closure Date:
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| 17-03860-100 | Healthcare Inspection—Medical Foster Home Program Concerns, Chalmers P. Wylie VA Ambulatory Care Center, Columbus, Ohio | Hotline Healthcare Inspection | ||
1 The Under Secretary for Health amends Medical Foster Home policy to include processes for reporting Medical Foster Home revocations to appropriate authorities to ensure current and future resident safety.
Closure Date:
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| 17-01756-86 | Comprehensive Healthcare Inspection Program Review of the Miami VA Healthcare System, Miami, Florida | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures clinical managers consistently review Ongoing Professional Practice Evaluation data every 6 months and monitors the managers’ compliance.
Closure Date:
2 The Chief of Staff ensures Physician Utilization Management Advisors consistently document their decisions in the National Utilization Management Integration database and monitors compliance.
Closure Date:
3 The Facility Director ensures patient transfer data for transfers out of the facility are collected, analyzed, and reported to an identified quality oversight committee and monitors compliance.
Closure Date:
4 The Associate Director ensures all areas of the facility are inspected at the required frequency and monitors compliance.
Closure Date:
5 The Associate Director ensures core team members consistently participate in environment of care rounds and monitors compliance.
Closure Date:
6 The Associate Director ensures locked mental health unit panic alarm testing documentation includes VA Police response time and monitors compliance.
Closure Date:
7 The Chief of Staff ensures that providers notify patients of changes in who is performing the moderate sedation procedure and document this in the electronic health record, and the Chief of Staff monitors providers’ compliance.
Closure Date:
8 The Chief of Staff ensures the Community Nursing Home Oversight Committee meets at least quarterly, includes representation by all required disciplines, and demonstrates integration with the facility quality improvement program, and the Chief of Staff monitors compliance.
Closure Date:
9 The Chief of Staff ensures the Community Nursing Home Review Team completes the required annual reviews for the community nursing homes and monitors managers’ compliance.
Closure Date:
10 The Chief of Staff ensures social workers and registered nurses conduct and document cyclical clinical visits with the frequency required by Veterans Health Administration and monitors compliance.
Closure Date:
11 The Chief of Staff ensures that Domiciliary Residential Rehabilitation Treatment Program employees in units 5A and 5D conduct and document daily resident room inspections for unsecured medications and monitors compliance.
Closure Date:
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| 16-02695-51 | Review of Excessive Procurement Costs at VHA’s Rural Outreach Clinic in Laughlin, Nevada | Audit | ||
1 The OIG recommended the Executive in Charge, Veterans Health Administration, ensure required oversight reviews are conducted and documented prior to the award of leases, contracting officers perform acquisitions in accordance with Department of Veterans Affairs and Federal Acquisition Regulation requirements, and awarded lease rates are in the best interest of the government.
Closure Date:
2 The OIG recommended the Executive in Charge, Veterans Health Administration, ensure the lease for the Laughlin Rural Outreach Clinicis is reevaluated to determine the financial advantages and disadvantages of renegotiating the terms of the contract to obtain a Fair Rental Value commensurate with the Laughlin Nevada area.
Closure Date:
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| 17-01745-96 | Comprehensive Healthcare Inspection Program Review of the VA Black Hills Health Care System, Fort Meade, South Dakota | Comprehensive Healthcare Inspection Program | ||
1 The Facility Director ensures inter-facility patient transfer data are analyzed and reported to a quality oversight committee as part of the facility’s quality management program and monitors compliance.
Closure Date:
2 The Associate Director ensures required team members participate in environment of care rounds and monitors compliance.
Closure Date:
3 The Associate Director ensures the locked mental health unit’s seclusion room bed is secured to the floor.
Closure Date:
4 The Associate Director ensures that locked mental health unit employees and members of the Interdisciplinary Safety Inspection Team complete the required training for the identification and correction of environmental hazards, including the proper use of the Mental Health Environment of Care Checklist, and the Associate Director monitors compliance.
Closure Date:
5 The Chief of Staff ensures that providers assess for patients’ previous adverse experiences with sedation or anesthesia prior to performing moderate sedation procedures and monitors compliance.
Closure Date:
6 The Chief of Staff ensures that clinical team members conduct timeouts using a checklist with all the required elements prior to performing moderate sedation procedures and monitors compliance.
Closure Date:
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14957